Endocrine pt 1

Question 1

Describe how to palpate the thyroid

Answer 1

1) Inspect the seated patient from the front and the side
2) Palpate the thyroid from behind the patient using the finger pads to palpate the lobes.
3) The patient’s neck should be slightly flexed to relax the neck muscles
4) After locating the cricoid cartilage- the isthmus can be identified and followed laterally to locate either lobe
5) By asking the patient to swallow (with water if needed), thyroid consistency can be appreciated

Question 2

What 3 things does T3/T4 do?

Answer 2

Makes you metabolically active!
1) Movement
2) Metabolism
3) Mentation

Question 3

Define primary, secondary, and tertiary thyroid disorders

Answer 3

1) Primary disorder
The thyroid is the problem
2) Secondary disorder
The pituitary gland is the problem
3) Tertiary disorder
The hypothalamus is the problem
(Almost never happens)

Question 4

How do you diagnose thyroid issues?

Answer 4

1) Order TSH
2) Confirm with Free T3/T4
-In Primary hypERthyroid disease T3/T4 will be high and TSH will be low
-In central hypERthyroid pituitary disease, TSH will be high and T3/T4 will be high
-Primary hypOthyroid disease T3/T4 will be low and TSH will be high
-In central hypOthyroid disease, TSH will be low and T3/T4 will be low

Question 5

Describe RAIU scan and what 4 things it can differentiate between

Answer 5

Pt is administered radioactive iodine, and the scan measures its uptake, which helps you to differentiate between the following:
-Graves disease
-Toxic multinodular goiter
-Toxic adenoma
-Thyroiditis

Question 6

Hyperthyroid: What can happen to the:
1) Heart
2) Gut
3) Brain

Answer 6

1) Increased HR and contractility > watch out for afib
2) Increased motility > watch for diarrhea
3) Increased activity > watch for insomnia, poor concentration, emotional lability

Question 7

Hyperthyroid: What can happen to the:
1) Bone
2) Temp
3) Metabolism
4) Nerves

Answer 7

1) Increased osteoclast activity > watch for osteopenia and hypercalcemia
2) Increased temp > watch for heat intolerance
3) Increased activity > watch for increased appetite AND weight loss
4) Increased sensitivity = increased DTRs
-& Tremor

Question 8

List the Sx of hypothyroidism

Answer 8

1) Bradyarrhythmia
2) Constipation
3) Fatigue, Lethargy > coma
4) Mental retardation and poor growth (in children)
-Called “cretinism”
-Look for macroglossia
-You can fix the poor growth, but you can’t correct mental retardation
5) Cold intolerance
6) Weight gain
7) Decreased DTR (with some exceptions)

Question 9

List some causes of hyperthyroidism

Answer 9

1) Graves Disease
2) Toxic multinodular goiter
3) Toxic adenoma
4) Pituitary Adenoma
5) Factitious / malingering
6) Struma Ovarii
7) Thyroid Storm *
8) Thyroiditis*

Question 10

Describe the pathogenesis of Grave’s

Answer 10

1) Type II hypersensitivity disease stimulating TSH receptors of the thyroid
2) Autoantibodies activate retroocular fibroblasts leading to orbitopathy

Question 11

Pt:
1) What are some Sx?
2) What will you see on PE?

Answer 11

1) Tachycardia, Diarrhea, Heat intolerance, Increased DTR, Weight loss +/- afib
Exophthalmos
2) Tremor, tachycardia
Proptosis, exophthalmos, lid lag pretibial myxedema
Pretibial Myxedema: Swollen red or brown patches on legs nonpitting edema

Question 12

How do you diagnose Grave’s? What are the lab levels?

Answer 12

1) TSH = low
2) T3/T4 = high
3) + TSH receptor antibodies
4) Riau scan = Diffuse increased iodine uptake

Question 13

Tx:
What is one way to Tx Grave’s? What are the downsides?

Answer 13

1) Radioactive iodine can be used
Ablates thyroid in 6-18 weeks
2) Contraindicated in pregnant/lactating women
Can make exophthalmos worse
Eye symptoms treated with steroids and surgery

Question 14

Tx: Thioamides for Grave’s:
1) Give 2 examples
2) What is their MOA?
3) What should you do in pregnancy?
4) What are some side effects?

Answer 14

1) Methimazole or propylthiouracil (PTU)
2) Prevents thyroid hormone synthesis
PTU also prevents peripheral conversion of T4
Methimazole has fewer side effects
3) PTU preferred in pregnancy; methimazole is teratogenic in 1st trimester
4) Agranulocytosis  monitor WBC’s
Hepatitis  monitor LFT’s

Question 15

Txs for Graves’; describe: when to use
1) Beta blockers
2) Steroids
3) Iodine

Answer 15

1) Used in acute, emergent treatment
2) Used in acute, emergent treatment
Also used to treat the ophthalmopathy
3) Used with extreme caution in acute, emergent treatment

Question 16

For Grave’s disease:
What if they have severe sx while pregnant
What if the goiter is causing compression?
What if they can’t take the meds and can’t get ablation?

Answer 16

Cut it out

Question 17

Toxic Multinodular Goiter / Toxic Adenoma:
1) What is the pathogenesis?
2) What are 2 Sx the pt will have?
3) How do you Dx?

Answer 17

1) T4 producing nodules on the thyroid
Because these nodules release T4, TSH will be low
Therefore, the remainder of the thyroid will be very cold on RAIU scan
2) Hyperthyroid sx
Palpable thyroid nodule
3) TSH > T3/T4
RAIU scan confirms diagnosis

Question 18

Toxic Multinodular Goiter / Toxic Adenoma:
What are 4 ways to Tx this? Which is most common?

Answer 18

1) Most common is Radioactive Iodine ablation
2) Surgery may be performed (esp if compressive symptoms from the mass)
3) Thionamides less preferred
4) +/- emergent therapy
Beta blockers, steroids

Question 19

TSH Secreting Pituitary Adenoma:
1) What is the pathogenesis?
2) What are the Sx in the pt?

Answer 19

1) Pituitary adenoma secreting TSH
2) Clinical hyperthyroidism
-May have structural change; bitemporal hemianopsia

Question 20

TSH Secreting Pituitary Adenoma:
1) How do you Dx?
2) How do you Tx?

Answer 20

1) TSH is high AND T4 is high!
RAIU shows diffuse uptake
For pituitary adenoma, MRI is always diagnostic
2) For pituitary adenoma, “transsphenoidal” is always the type of surgery
-Prior to surgery, somatostatin analogs may be used

Question 21

Factitious/Struma Ovarii:
1) What is the pathogenesis?
2) What are the Sx in the pt?

Answer 21

1) High T4 either from ovarian tumor or from taking meds to lose weight
2) Patient with weight loss and hyperthyroid sx

Question 22

Factitious/Struma Ovarii:
1) How do you Dx?
2) How do you Tx?

Answer 22

1) RAIU scan = cold thyroid
Struma patient will have an ovarian mass
2) Remove mass OR “stop doing that”

Question 23

Thyroid storm:
1) What is the pathogenesis?
2) What are the many Sx seen in the pt?

Answer 23

1) Severe hyperthyroid state
2) Tachycardia; maybe a. fib
-GI upset > diarrhea
-Heart failure
-Hyperthermia
-CNS dysfunction
-Often there is a precipitating event – trauma, infection, pregnancy, but not always

Question 24

Thyroid storm: How do you Dx?

Answer 24

Get TSH –> T3/T4
-However, you’ll get the diagnosis from the TSH and symptoms seen above

Question 25

How do you Tx thyroid storm?

Answer 25

1) Nonselective beta blocker: **propranolol IV** Helps slow HR and blocks the body’s response to T3/T4 2) Thioamides: methimazole or PTU (preferred) 3) Steroids (dexamethasone) 4) Antipyretic (Tylenol preferred) 5) Be careful with Iodine! -ICU

Question 26

List some causes of hypothyroid

Answer 26

Hashimoto’s Subclinical Hypothyroid Cretinism Myxedema Coma Thyroiditis*

Question 27

Describe the Tx of Hashimoto's

Answer 27

1) Levothyroxine is 1st line -Indicated if TSH 10mlU/L or greater -MOA: synthetic T4 -Monitor TSH q 6 weeks to titrate the dose -Start low and go slow; will need to increase during pregnancy 2) Best taken in the morning 3) Don’t take with multivitamins, iron/calcium supplementation, or PPI -All these decrease effectiveness 5) Caution against overshooting and causing hyperthyroid *doses will need to increase during pregnancy

Question 28

Describe levothyroxine doses for Hashimoto's

Answer 28

1) Usually 50 – 200 mcg /day Children- 4mcg / kg / day Adults - 1.6mcg/ kg/ day Elderly- 1 mcg/ kg/ day 2) Start low dose in patients with stable CAD and in elderly 3) Usual starting dose is 50mcg in adults and 25mcg in elderly patients

Question 29

Describe follow-up with Hashimoto's Tx

Answer 29

1) Begin follow up testing every 6 weeks -Test patients on Thyroid replacement every 6 to 12 months once stable. -Test patients more often with severe illness 2) Several meds can change absorption of thyroid hormones which may require more freq monitoring coumadin, antidepressants, antidiabetics

Question 30

Hashimoto's: When should you f/u Q4-6 wks?

Answer 30

If TSH is not stable Recent change in dose Recent change in manufacturer

Question 31

Hashimoto's f/: What are the normal lab levels?

Answer 31

TSH- 0.40 – 4.2 mIU/L Free T4- 0.8- 2.8 ng/dL Free T3- 2.3- 4.2 pg/mL

Question 32

What are the 2 options for the Tx of subclinical hypothyroid?

Answer 32

1) You can observe them and recheck 2) You can definitely give levothyroxine if the TSH is 10mU/L or higher This has been shown to prevent cardiovascular side effects down the line Why, this can stave off adverse cardiovascular effects of subclinical hypothyroidism

Question 33

Why is brand name important for Hashimotos?

Answer 33

Each strength of thyroid hormone has a different color and shape. Patients should always be familiar with “their brand or generic”- if the manufacturer is changed- it can affect absorption and lab values Always discuss medicine compliance with your patients.

Question 34

Describe subclinical hypothyroid

Answer 34

You will see patients with abnormal labs Increased TSH But they have little or no symptoms And the T4 is normal. . .

Question 35

Cretinism: 1) Describe the pathogenesis 2) How do you Dx?

Answer 35

1) Congenital hypothyroidism Lack of iodine in third world Dysgenesis of the thyroid gland Maternal antithyroid antibodies cross the placenta 2) Clinical + increased TSH and low T3/T4

Question 36

Cretinism: 1) What are the Sx in the pt? What abt on PE? 2) How do you Tx?

Answer 36

1) Delayed mental development Hypothyroid symptoms Goiter in older children PE Coarse facial features, macroglossia, umbilical hernia, hypotonia, jaundice, feeding problems, 2) Levothyroxine

Question 37

Myxedema Coma: 1) What is the pathogenesis? 2) What will you see in the pt? Who is it more common in?

Answer 37

1) Extreme form of hypothyroidism Emergency 2) Elderly woman in the winter Bradycardia, hypothermia, hypotension Potential coma

Question 38

Myxedema Coma: 1) How do you Dx? 2) How do you Tx?

Answer 38

1) Critical patient with Hypothyroid labs 2) Levothyroxine

Question 39

List 2 additional common causes of hypothyroidism

Answer 39

Thyroid ablation from radioactive iodine Thyroidectomy

Question 40

List some less common causes of hypothyroidism

Answer 40

1) Neck radiation from cancer treatment 2) Medications Amiodarone – contains iodine type molecule Lithium – not fully understood Iodine 3) Secondary or central hypothyroidism (5% of cases) Pituitary necrosis Pituitary lesion HIV infxn Congenital Brain trauma

Question 41

List 6 causes of thyroiditis

Answer 41

Hashimoto’s Silent thyroiditis Post partum thyroiditis Subacute/de Quervain Riedel’s Suppurative

Question 42

Describe the pathogenesis of thyroiditis

Answer 42

Normal thyroid becomes inflamed, causing transient release of T4, but decreased uptake of new iodine Subsequent return to normal thyroid function Or subsequent permanent loss of function

Question 43

Thyroiditis: 1) What does it look like in the pt? 2) How do you Dx?

Answer 43

1) Hyperthyroid sx  hypothyroid symptoms +/- thyroid pain 2) RAIU scan is cold because no new T4 is being made during this period

Question 44

Thyroiditis: 1) How do you Tx? 2) What f/u is needed? Why?

Answer 44

1) Not definitive, and dependent upon cause -Pain, if present, treated with NSAID -Clinical judgment dictates amelioration of hyperthyroid symptoms 2) Thyroiditis is sometimes a precursor to hypothyroidism; f/u with labs

Question 45

Silent (lymphocytic) / Postpartum: 1) Describe the pathogenesis 2) Describe the Sx in the pt

Answer 45

1) Autoimmune response; antithyroid antibodies TPO, TG 2) Painless, enlarged thyroid Thyrotoxicosis may occur in early stage HypOthyroid later Returns to euthyroid in 12-18 months

Question 46

Silent (lymphocytic) / Postpartum: 1) How do you Dx? 2) How do you Tx?

Answer 46

1) Either hyperthyroid early in disease Or hypothyroid later 2) NO thyroid meds  will return to normal on its own Aspirin or NSAID 20% chance of permanent hypothyroidism

Question 47

Subacute / Dequervain Thyroiditis (also called granulomatous): 1) What is the pathogen.? 2) What are the Sx in the pt?

Answer 47

1) Often follows viral illness Possible autoimmune correlation with viral antigen Also called granulomatous thyroiditis 2) Hyperthyroid  hypothyroid Painful thyroid gland Worse with head movements and deglutition Radiates from lower neck to jaw and ear

Question 48

Subacute / Dequervain Thyroiditis (also called granulomatous): What will you see on PE?

Answer 48

Diffusely tender goiter

Question 49

Subacute / Dequervain Thyroiditis (also called granulomatous): Describe how you Dx (besides PE)

Answer 49

Primary hyperthyroid profile early in the disease  may shift to euthyroid profile  hypothyroid profile Normal thyroid antibodies High ESR! Pt may be hypothyroid High TSH, low T4 Usually lasts 12-18 months Radioactive uptake scan shows diffusely decreased uptake Biopsy Would granulomatous cells multinucleated giant cells

Question 50

Riedel’s Thyroiditis: 1) Pathogen? 2) Pt?

Answer 50

1) Chronic autoimmune disease Fibrosis that invades thyroid and adjacent neck structures IgG-4 related illness 2) Rock hard nontender thyroid Rapidly growing thyroid Compression symptoms Neck tightness, pressure, hoarseness, dysphagia, chocking, coughing, tachypnea from airway compression Will not have LAD

Question 51

Riedel’s Thyroiditis: 1) Dx? 2) Tx?

Answer 51

1) IgG-4 serum levels May be euthyroid on TSH/T4 workup about 30% of the time Diagnosis made with thyroid biopsy that reveals dense fibrosis Careful, the “rock hard” thyroid is also seen in anaplastic thyroid cancer Biopsy distinguishes the two 2) Surgical management

Question 52

Suppurative Thyroiditis: 1) Pathogen? 2) Pt: Who is it found in? What are the Sx?

Answer 52

1) Bacterial infection of the thyroid Usually gram-positive bacteria – staph aureus 2) Child Thyroid pain and tenderness with acute onset Worse with hyperextension, improved with flexion May radiate to jaw, ears, or posterior skull May have erythema on overlying skin Fever, chills, pharyngitis, dysphagia, dysphonia, hoarseness

Question 53

Suppurative Thyroiditis: 1) Dx? 2) Tx?

Answer 53

1) Lab: leukocytosis and elevated ESR Normal thyroid labs Thyroid ultrasound 2) Antibiotics Surgical drainage if fluctuant

Question 54

Give a recap of the following types of thyroiditis: 1) Hashimoto’s (we’ve already done) 2) Silent thyroiditis / postpartum thyroiditis

Answer 54

1) Painless Antibodies against thyroid peroxidase and thyroglobulin 2-6 weeks of hyperthyroidism followed by permanent hypothyroidism Most common cause in the U.S. 2) Transient hyperthyroid followed by hypothyroid state that normalizes in 12-18 months

Question 55

Give a recap of the following types of thyroditis: 1) Subacute Granulomatous/De Quervain’s 2) Riedel's thyroiditis 3) Suppurative Thyroiditis

Answer 55

1) Viral illness > hyperthyroidism that normalizes in 12-18 months (permanent in rare cases) Painful thyroid! 2) Chronic inflammation and fibrosis of the thyroid in young adults 3) Bacterial infection of the thyroid